Patient profile and outcomes of traumatic injury: The impact of mode of arrival to the emergency department

BackgroundTraumatic injuries are of global health concern and significant contributors to Emergency Department (ED) and hospital workload.AimTo compare patterns of traumatic injuries among patient presentations to the ED across different modes of arrival (ambulance, police, or private transport) and to examine the predictors of an ED length of stay (LOS) exceeding 4 hours and hospital admission requirement.MethodsA retrospective observational study using 6 months of health data (8th October 2012–7th April 2013) of ED patient presentations made to one large, regional ED in Queensland, Australia, with a diagnosis code related to trauma.FindingsOver 6 months, 24.2% (n = 6,668) of adult patient presentations were trauma-related; most (60.9%) arrived via privately arranged transport (PAT); 38.7% were brought in by ambulance (BIBA) and 0.4% were brought in by police (BIBP). Demographics, clinical profile and patient outcomes differed based on mode of arrival. One in four patient presentations required hospital admission and 25% had an ED length of stay of >4 hours. Factors influencing hospital admission included older age, night shift, more emergent priority, and being BIBA. An ED length of stay of >4 hours was associated with older age, being BIBA, emergent nature of presentation, and hospital admission.ConclusionThe profile and outcomes of ED patient presentations with traumatic injury differs based on their mode of arrival to the ED. People BIBA were more likely to require hospital admission and have longer ED LOS, compared with those BIBP or PAT, even when controlling for covariates. Our findings may be used to inform nursing resource allocation when considering mode of arrival, especially for older people and people BIBA.     

Profiling police presentations of mental health consumers to an emergency department

Public mental health systems have been called on to better meet the needs of consumers presenting to health services with the police, yet few studies have examined police presentations among mental health consumers in large public mental health systems. This study was designed to determine the frequency profile and characteristics of consumers of mental health services brought in by police to an emergency department (ED) in Sydney, Australia. Using data from the emergency department information system and obtaining the psychiatric assessment from the medical record, we have examined trends and characteristics in mental health presentations brought in by the police to a general ED between 2003 and 2005. The sample consisted of 542 consumers with a mental health problem brought in by the police to the ED of a 350-bed community hospital. The characteristics of this group were compared with those of all mental health related ED presentations for the same period using logistic regression. Results indicated that police presentations are likely to be young males who are unemployed, have past and present alcohol and other drugs use, present after hours, and are admitted to hospital as a result of their presentation. These consumers are likely to have a presenting problem of a psychotic disorder, less likely to have a presenting problem of depression and/or anxiety, and given a triage code of three or higher. The study results highlight the importance of the availability of 24-hour access to mental health care to ensure a quick care delivery response. Police presentations to EDs with mental health issues are an indicator of significant impact on health services, especially with the current overcrowding of EDs and the associated long waiting times. Systems need to be developed that facilitate collaboration between EDs, hospital security, police services, mental health, and ambulance services.     

People brought to the emergency department under involuntary assessment orders: A scoping review

BackgroundSome people with mental health problems arrive to the Emergency Department (ED) under involuntary assessment orders (IAOs) and can have complex medical and socioeconomic factors, which may impact on the delivery of care in the ED. Therefore, this scoping review aimed to identify, evaluate and summarise the current literature regarding the demographic characteristics, clinical characteristics and outcomes for people brought to the ED under IAOs.MethodA scoping review was undertaken guided by the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) Guidelines and the Arksey and O’Malley framework.ResultsIn total 21 articles were included in this review. People under IAOs most commonly present to EDs with suicidal ideation/intent, with interagency involvement noted when responding to these people in the pre-hospital setting. Most people arriving to ED under IAOs were reported to experience length of stay longer than four hours.ConclusionThis review highlights the limited information pertaining to people brought to EDs under an IAO. High levels of mental health problems and extended length of stay for people under IAOs suggests the need for interagency collaboration to inform the development and implementation of models of care that incorporates social determinants of health and are tailored to this complex population.     

Involuntary psychiatric attendances at an Australasian emergency department: A comparison of police and health‐care worker initiated presentations

Objective: To identify any significant differences in the population of patients brought in to a hospital ED under involuntary mental health orders, based on whether the orders are initiated by police or health professionals. Methods: A retrospective analysis of consecutive presentations to a tertiary hospital ED with a co‐located psychiatric emergency care centre over a 12 month period, with univariate and multivariate statistical comparisons. Results: Two hundred and eighty‐two patients (making 378 ED presentations) met the case definition and were analysed. Compared with patients on medical orders, patients on police orders had significantly more presentations related to violence, longer stays in ED and lower rates of admission to an inpatient bed, but were no more likely to require restraint or security intervention within the ED. Conclusions: Patients on police and medical orders differ considerably, but the impact of these differences on ED workload is small.     

Emergency nurses’ perceptions of the health care system and how it impacts provision of care to people who self-harm

BackgroundSelf-harm is a deliberate act to cause physical harm to oneself. People who self-harm are at greater risk for suicide than people who do not self-harm. Emergency nurses are first responders to many people who present to the emergency department (ED) with self-harm. The care they provide can influence future presentations to the emergency department and long-term outcomes.AimThe aim was to explore ED nurses’ experiences of working with people who self-harm.MethodsSemi-structured interviews were conducted with 18 emergency nurses from different locations in Australia in 2019. Elo and Kyngäs’ inductive content analysis research method guided all stages of the research.ResultsThe category “health care system” emerged from the data. It comprised five subcategories: (i) Complexity of the work environment; (ii) ED staff attitudes and care provision; (iii) the mental health patient; (iv) facilitators and barriers to providing care to people who self-harm; and (v) lack of community resources.DiscussionThis study found there were several factors influencing ED nurses’ knowledge, skills and confidence in caring for people who self-harm and several factors influenced their experience.ConclusionWhile participants felt confident to manage the physical injuries associated with self-harm, they were less confident to engage with the person about their self-harm. The article provides guidance for ED nurses to assess and intervene with people who present with self-harm.     

Systematic review of trends in emergency department attendances: an Australian perspective

Emergency departments (EDs) in many developed countries are experiencing increasing pressure due to rising numbers of patient presentations and emergency admissions. Reported increases range up to 7% annually. Together with limited inpatient bed capacity, this contributes to prolonged lengths of stay in the ED; disrupting timely access to urgent care, posing a threat to patient safety. The aim of this review is to summarise the findings of studies that have investigated the extent of and the reasons for increasing emergency presentations. To do this, a systematic review and synthesis of published and unpublished reports describing trends and underlying drivers associated with the increase in ED presentations in developed countries was conducted. Most published studies provided evidence of increasing ED attendances within developed countries. A series of inter-related factors have been proposed to explain the increase in emergency demand. These include changes in demography and in the organisation and delivery of healthcare services, as well as improved health awareness and community expectations arising from health promotion campaigns. The factors associated with increasing ED presentations are complex and inter-related and include rising community expectations regarding access to emergency care in acute hospitals. A systematic investigation of the demographic, socioeconomic and health-related factors highlighted by this review is recommended. This would facilitate untangling the dynamics of the increase in emergency demand.     

Subtle oncological emergencies: Nature of illness,clinical characteristics,and outcomes

ObjectivesThe primary objective was to assess whether presentation severity at the emergency department (ED) can determine treatment and health outcomes among patients with oncological emergencies.MethodsWe conducted a three-year retrospective analysis of accessible records of adult cancer patients admitted with oncological emergencies.ResultsPatients with subtle presentations had longer wait times than patients with severe presentations in all ED timeliness indicators. On average, subtle presentations were significantly associated with 47.5 min increase in time to be seen, 33 min increase in time to be treated, 42 min increase in time to decide on admission and prolonged ED stay by 24 min (p < 0.05). Subtle presentations were also significantly associated with a four-fold increase in intensive care unit admissions and a three-fold increase in mortality odds.ConclusionThe severity of the clinical presentations significantly predicted oncological emergencies' treatment and health outcomes. This research raises the importance of emergency triage decision accuracy. Triage health workers should have a solid knowledge base regarding oncological emergencies to improve patients’ early recognition and prioritization. Oncological emergency presentations can be subtle, rendering patients vulnerable extensive delay and inferior outcomes. Therefore, triage nurses should be educated and trained on the multiple available severity scales sensitive to identifying the real urgency. Also, protocols and care pathways should be in place to enable immediate fast-tracking of patients and the provision of timely treatment.     

Models of care for frail older persons who present to the emergency department: A scoping review of the literature

BackgroundPeople aged ≥65 years comprise approximately 20 % of all emergency department (ED) presentations. Frailty amongst this cohort is common yet can go undetected.ObjectiveTo summarise the evidence regarding models of care for frail older people in the ED.MethodsThe Joanna Briggs Institute scoping review framework was used. Literature searches were conducted in five electronic databases published from 2009 to 2022. Original research that met the criteria: frail older people aged ≥65 years, models of care and ED were included.ResultsA total of thirteen articles met the criteria for inclusion in this review. These comprised four studies of frailty care models and nine studies of care models using different assessment tools to identify frail older people. Care models were comprised of various specialist team members (e.g., geriatrician/ED physician and nurse). Processes underpinning these models included tools to support clinicians in the assessment of frail older adults, particularly around functional status, comorbidities, symptom distress, quality of life, cognition/delirium, and social aspects. Outcomes of care models for frail older people included: shorter ED length of stay, lower hospital admission rates, cost savings and increased patient satisfaction rates.ConclusionA variety of models, supported by a variety of assessment tools, exist to identify and guide care delivery for frail older people in the ED. Careful consideration of existing policies, guidelines and models is required before implementing new service models.     

The triage of psychiatric patients in the hospital emergency department: a comparison between emergency department nurses and psychiatric nurse consultants

The triage of patients in the hospital emergency department (ED) has developed as an efficient method to determine the level of urgency and provide appropriate care and treatment. The triage process has been found to be less effective for patients presenting with mental health related problems. Triage guidelines specifically tailored for mental health needs have been introduced in the attempt to overcome existing problems, however, the effectiveness of these guidelines has not been extensively tested. This paper presents the findings of a study conducted in a large metropolitan hospital in Melbourne, Australia. All presentations to the ED for psychiatric problems (n = 137) were triaged using the mental health guidelines over a 3-month period. The same presentations were triaged by psychiatric nurse consultants employed in the ED and the results compared. The results indicate a high level of difference in the triage ranking by the two groups of nurses, with emergency nurses tending to classify presentations as more urgent than their psychiatric nurse colleagues. These findings suggest that mental health education for emergency nurses is necessary if the guidelines are to be used effectively and improve outcomes for patients presenting with psychiatric problems.     

Managing people with mental health presentations in emergency departments-A service exploration of the issues surrounding responsiveness from a mental health care consumer and carer perspective

Mainstreaming of mental health services (MHS) within the Australian medical system has generated a fundamental transformation in the way consumers and carers access emergency MHS. People present to the Emergency Department (ED) with many health issues which can often include the management of their mental illness, physical co morbidity, or substance use. This paper discusses the issues surrounding access to EDs for clients, families and staff in the context of presentations for mental health problems at a southern metropolitan hospital in Victoria. The pilot project utilised focus groups with mental health care consumers and carers to collaboratively focus on and document the mental health client's 'journey of care' in the ED. There is evidence to suggest from this project that the ED mental health client journey needs continuous improvement and evaluation.     

Review article: End‐of‐life care for older people in the emergency department: A scoping review

Older people are increasingly utilising emergency services, often at the end of their life. This scoping review aimed to provide a comprehensive understanding of available research regarding end‐of‐life (EOL) care for older people in the ED. The Joanna Briggs Institute scoping review methodology guided this review. Databases of CINAHL, Ovid MEDLINE, Embase, SocINDEX and Google Scholar were searched using a combination of terms, including older/aged/geriatrics/elderly, palliative/terminal/end‐of‐life and emergency/emergency service. The search was limited to articles published in English from 2007 to 2018. The level of evidence of included articles was assessed using the National Health and Medical Research Council (NHMRC) criteria. Fourteen articles were included. Definitions pertaining to EOL care in the ED vary. Older people presenting to ED at EOL were mostly female, triaged in urgent or semi‐urgent category, presented with diagnoses of advanced cancer, cardiac and pulmonary disease, and dementia with symptoms including pain and breathlessness. Multiple tools pertaining to EOL exist and range from predicting mortality, and assessing functional status, co‐morbidities, symptom distress, palliative care needs, quality of life and caregiver's stress. Outcomes for older people enrolled in specific EOL intervention programmes included lower admission rates, shorter ED length of stay, increased palliative care referral and consultations, and decreased Medicare costs. The NHMRC evidence level of included articles ranged from II to IV. Limited evidence exists regarding the definition, clinical profile, care delivery and outcomes for older people requiring EOL care in the ED. Future research and clinical practice that uses current evidenced‐based policies and guidelines is required.     

Knowledge and confidence of Australian emergency department clinicians in managing patients with mental health-related presentations: findings from a national qualitative study

Background

Mental health related presentations are common in Australian Emergency Departments (EDs). We sought to better understand ED staff knowledge and levels of confidence in treating people with mental health related problems using qualitative methods.

Methods

This was a qualitative learning needs analysis of Australian emergency doctors and nurses regarding the assessment and management of mental health presentations. Participants were selected for semi-structured telephone interview using criterion-based sampling. Recruitment was via the Australasian College for Emergency Medicine and College of Emergency Nursing Australasia membership databases. Interviews were audio-recorded and transcribed verbatim. Thematic framework analysis was used to identify perceived knowledge gaps and levels of confidence among participants in assessing and managing patients attending EDs with mental health presentations.

Results

Thirty-six staff comprising 20 doctors and 16 nurses consented to participate. Data saturation was achieved for four major areas where knowledge gaps were reported. These were: assessment (risk assessment and assessment of mental status), management (psychotherapeutic skills, ongoing management, medication management and behaviour management), training (curriculum and rotations), and application of mental health legislation. Participants’ confidence in assessing mental health patients was affected by environmental, staff, and patient related factors. Clinicians were keen to learn more about evidence based practice to provide better care for this patient group. Areas where clinicians felt the least confident were in the effective assessment and management of high risk behaviours, providing continuity of care, managing people with dual diagnosis, prescribing and effectively managing medications, assessing and managing child and adolescent mental health, and balancing the caseload in ED.

Conclusion

Participants were most concerned about knowledge gaps in risk assessment, particularly for self-harming patients, violent and aggressive patients and their management, and distinguishing psychiatric from physical illness. Staff confidence was enhanced by better availability of skilled psychiatric support staff to assist in clinical decision-making for complex cases and via the provision of a safe ED environment. Strategies to enhance the care of patients with mental health presentations in Australian emergency departments should address these gaps in knowledge and confidence.     

Police and mental health clinician partnership in response to mental health crisis: A qualitative study

Police officers as first responders to acute mental health crisis in the community, commonly transport people in mental health crisis to a hospital emergency department. However, emergency departments are not the optimal environments to provide assessment and care to those experiencing mental health crises. In 2012, the Northern Police and Clinician Emergency Response (NPACER) team combining police and mental health clinicians was created to reduce behavioural escalation and provide better outcomes for people with mental health needs through diversion to appropriate mental health and community services. The aim of this study was to describe the perceptions of major stakeholders on the ability of the team to reduce behavioural escalation and improve the service utilization of people in mental health crisis. Responses of a purposive sample of 17 people (carer or consumer advisors, mental health or emergency department staff, and police or ambulance officers) who had knowledge of, or had interfaced with, the NPACER were thematically analyzed after one‐to‐one semistructured interviews. Themes emerged about the challenge created by a stand‐alone police response, with the collaborative strengths of the NPACER (communication, information sharing, and knowledge/skill development) seen as the solution. Themes on improvements in service utilization were revealed at the point of community contact, in police stations, transition through the emergency department, and admission to acute inpatient units. The NPACER enabled emergency department diversion, direct access to inpatient mental health services, reduced police officer ‘down‐time’, improved interagency collaboration and knowledge transfer, and improvements in service utilization and transition.     

Mental health emergencies: using a structured assessment framework

People who have mental health crises while attending emergency departments (EDs) require immediate assessment and management, and ED staff must be prepared to meet the specific needs of this client group. This article gives an overview of the public psychiatric emergency assessment tool (Wright et al 2008), which is used by, for example, the Lancashire Constabulary to share information with healthcare professionals. By using the tool, practitioners can organise and structure the information they acquire during patient assessments, and from accompanying carers, paramedics, or police. They can then pass this information on to mental health specialists.     

Review article: People who present on multiple occasions to emergency departments

Research about people who present on multiple occasions to the ED began in the 1980s. Despite this, little is known of their journey as patients. Understanding ED use as a journey can help clinicians improve how they meet the needs of this patient group. Multiple terms were used to identify research on the use of the ED. Papers were included if they had a primary focus on multiple presentations by the general ED population. Integrative review methods were used to extract findings related to the patients' journeys. The findings confirm a sequence of events and processes that provide an outline of the journey through the experience of people who present on multiple occasions. The journey concerns people's decisions to present and re‐present to the ED, their assessments on arrival, dilemmas of treatment, outcomes of care and long‐term health outcomes. This patient group often have high and complex health needs, engage extensively with other health services and have poor long‐term health outcomes. The issue of multiple presentations to the ED is complex and ongoing because of the morbidity of the people concerned, the preference of patients to attend, the purpose of the ED and preparation and role of the personnel and the difficulties with continuity of care. The provision of care for people who present on multiple occasions can be improved within the ED and health services generally through a better understanding of presentations.